PSYCHIATRY III EXIMIUS

SLEEP-WAKE DISORDERS
Ethel Maureen Pagaddu, MD
SLEEP DISORDERS
Sleep Disorder Classification
1. Insomnia Disorder
2. Hypersomnolence Disorder
3. Narcolepsy
4. Breathing-Related Sleep Disorders:
a. Obstructive Sleep Apnea Hypopnea
b. Central Sleep Apnea
i. Idiopathic central sleep apnea
ii. Cheyne-Stokes breathing
iii. Central sleep apnea comorbid with opioid use
c. Sleep-Related Hypoventilation
5. Circadian Rhythm Sleep-Wake Disorders:
a. Delayed sleep phase type
b. Advanced sleep phase type
c. Irregular sleep-wake type
d. Non-24-hour sleep-wake type
e. Shift work type
f. Unspecified type
6. Parasomnias
7. Non-Rapid Eye Movement Sleep Arousal Disorders:
a. Sleepwalking type
b. Sleep terror type
8. Nightmare Disorder
9. Rapid Eye Movement Sleep Behavior Disorder
10. Restless Legs Syndrome
11. Substance/Medication-Induced Sleep Disorder
2021
December 2019
awakenings. (In children, this may manifest as difficulty
returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to
sleep.
B. The sleep disturbance causes clinically significant distress or
impairment in social, occupational, educational, academic,
behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur
exclusively during the course of another sleep-wake disorder (e.g.,
narcolepsy, a breathing-related sleep disorder, a circadian rhythm
sleep-wake disorder, a parasomnia).
G. The insomnia is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not
adequately explain the predominant complaint of insomnia.
Specify if:
With non-sleep disorder mental comorbidity, including substance
use disorders
With other medical comorbidity With other sleep disorder Coding
note: The code 780.52 (G47.00) applies to all three specifiers. Code
also the relevant associated mental disorder, medical condition, or
other sleep disorder immediately after the code for insomnia
disorder in order to indicate the association.

COMMON POLYSOMNOGRAPHIC MEASURES Specify if:

§ Sleep latency: Period of time from turning out the lights until
the appearance of stage II sleep
§ Early morning awakening: Time of being continuously awake
from the last stage of the sleep until the end of the sleep record
(usually at 7 AM)
§ Sleep efficiency: Total sleep time or total time of the sleep
record x 100
§ Apnea index: Number of apneas longer than 10 seconds per
hour of sleep
§ Nocturnal myoclonus index: Number of periodic leg
movements per hour
§ Rapid eye movement (REM) latency: Period of time from the
onset of sleep until the first REM period of the night
§ Sleep-onset REM period: REM sleep within the first 10 minutes
of sleep.
Episodic: Symptoms last at least 1 month but less than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.
Note: Acute and short-term insomnia (i.e., symptoms lasting less
than 3 months but otherwise meeting all criteria with regard to
frequency, intensity, distress, and/or impairment) should be coded
as an other specified insomnia disorder.
HYPERSOMNOLENCE DISORDER
§ Sleepiness can be a consequence of
(1) insufficient sleep,
(2) basic neurologic dysfunction in brain systems
regulating sleep,
(3) disrupted sleep, or
(4) the phase of an individual's circadian rhythm.

INSOMIA DISORDER PARASOMNIA

§ difficulty initiating or maintaining sleep
§ the most common sleep complaint and may be transient or
persistent
§ DSM-5 defines insomnia disorder as dissatisfaction with sleep
quantity or quality associated with one or more of the following
symptoms: difficulty in initiating sleep, difficulty in maintaining
sleep with frequent awakenings or problems returning to sleep,
and early morning awakening with inability to return to sleep
DSM-5 Diagnostic Criteria for Insomnia Disorder
A. A predominant complaint of dissatisfaction with sleep quantity or
quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest
as difficulty initiating sleep without caregiver intervention.
2. Difficulty maintaining sleep, characterized by frequent
awakenings or problems returning to sleep after
§ an unusual or undesirable phenomenon that appears suddenly
during sleep OR THAT occurs at the threshold between waking
and sleeping
§ occurs in stages III and IV and, thus, is associated with poor
recall of the disturbance
SLEEP-WAKE SCHEDULE DISTURBANCE
§ involves the displacement of sleep from its desired circadian
period
§ cannot sleep when they wish to sleep; they cannot be fully
awake when they want to be fully awake
Nonspecific Measures to Induce Sleep (Sleep Hygiene)
§ Arise at the same time daily.
§ Limit daily in-bed time to the usual amount present before the
sleep disturbance.
§ Discontinue central nervous system (CNS)-acting drugs
(caffeine, nicotine, alcohol, stimulants).

TRANSCRIBERS Marky, Josh, Eina 1

 PSYCHIATRY III
SLEEP-WAKE DISORDERS
Ethel Maureen Pagaddu, MD December 2019
§ Avoid daytime naps (except when sleep chart shows they
induce better night sleep).
§ Establish physical fitness by means of a graded program of
vigorous exercise early in the day.
§ Avoid evening stimulation; substitute radio or relaxed reading
for television.
§ Try very hot, 20-minute, body-temperature-raising bath soaks
near bedtime.
§ Eat at regular times daily; avoid large meals near bedtime.
§ Practice evening relaxation routines, such as progressive
muscle relaxation or meditation.
§ Maintain comfortable sleeping conditions.
Inadequate Sleep Hygiene
§ a patient's lifestyle leads to sleep disturbance
§ referring to a problem in following generally accepted
practices to aid sleep
§ include keeping regular hours of bedtime and arousal,
avoiding excessive caffeine, not eating heavy meals before
bedtime, and getting adequate exercise.
§ sometimes falls within the primary insomnia classification
depending on the specific sleep hygiene factor involved
§ Treatment should focus on only two or three problem areas at
a time
PSYCHOPHYSIOLOGICAL INSOMNIA
§ presents as a primary complaint of difficulty in going to sleep
§ may describe this as having gone on for years and usually
denies that it is associated with stressful periods in his or her
life
§ also called conditioned insomnia
§ Other features include (1) excessive worry about not being
able to sleep; (2) trying too hard to sleep; (3) rumination,
inability to clear one's mind while trying to sleep; (4) increased
muscle tension when attempting to sleep; (5) other somatic
manifestations of anxiety; (6) being able to sleep better away
from one's own bedroom; and (7) being able to fall asleep
when not trying (e.g., watching TV)
§ Treatment can be difficult
§ Sleeping pills be used sparingly and at the lowest effective
dose
§ Stimulus control therapy is recommended to break the
conditioning
§ relaxation therapy is a useful ancillary treatment
SLEEP STATE MISPERCEPTION
§ also known as subjective insomnia
§ characterized by a dissociation between the patient's
experience of sleeping and the objective polygraphic
measures of sleep
§ Cause is not yet understood
§ a patient complains of difficulty initiating or maintaining sleep
and no
objective evidence of sleep disruption is found
§ can occur in individuals who are apparently free from
psychopathology or it can represent a somatic delusion or
hypochondriasis
§ Cognitive relabeling, diffusing the worry about being unable to
sleep, or both can help
§ anxiolytics can profoundly reduce the perception of
sleeplessness
Specify whether:
347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin
deficiency: Criterion B requirements of low CSF hypocretin-1 levels
TRANSCRIBERS Marky, Josh, Eina
EXIMIUS
2021
IDIOPATHIC INSOMNIA
§ starts early in life, sometimes at birth, and continues
throughout life
§ suspected causes include neurochemical imbalance in
brainstem reticular formation, impaired regulation of
brainstem sleep generators (e.g., raphe nuclei, locus ceruleus),
or basal forebrain dysfunction
§ treatment is difficult
§ improved sleep hygiene, relaxation therapy, and judicious use
of hypnotic medicines are reportedly helpful
§ shows some familial incidence
§ most frequently begins in adolescence or young adulthood,
generally before the age of 30
§ either progresses slowly or reaches a plateau that is
maintained throughout life
§ The most common symptom is sleep attacks
§ Another uncommon symptom is sleep paralysis, most often
occurring on awakening in the morning; during the episode,
patients are apparently awake and conscious but unable to
move a muscle
§ HLA-DR2 is found in 90 to 100 percent of patients with
narcolepsy
§ patients with narcolepsy are deficient in the neurotransmitter
hypocretin, which stimulates appetite and alertness
NARCOLEPSY
DSM-5 Diagnostic Criteria for Narcolepsy
A. Recurrent periods of an irrepressible need to sleep, lapsing
into sleep, or napping occurring within the same day.
These must have been occurring at least three times per
week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or
(b), occurring at least a few times per month:
a. In individuals with long-standing
disease, brief (seconds to minutes)
episodes of sudden bilateral loss of
muscle tone with maintained
consciousness that are precipitated by
laughter or joking.
b. In children or in individuals within 6
months of onset, spontaneous
grimaces or jaw-opening episodes with
tongue thrusting or a global hypotonia,
without any obvious emotional
triggers.
2. Hypocretin deficiency, as measured using
cerebrospinal fluid (CSF) hypocretin-1
immunoreactivity values (less than or equal to
one third of values obtained in healthy subjects
tested using the same assay, or less than or
equal to 110 pg/ml). Low CSF levels of
hypocretin-1 must not be observed in the
context of acute brain injury, inflammation, or
infection.
3. Nocturnal sleep polysomnography showing rapid
eye movement (REM) sleep latency less than or
equal to 15 minutes, or a multiple sleep latency
test showing a mean sleep latency less than or
equal to 8 minutes and two or more sleep-onset
REM periods.
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 PSYCHIATRY III
SLEEP-WAKE DISORDERS
Ethel Maureen Pagaddu, MD December 2019
and positive polysomnography/multiple sleep latency test are met,
but no cataplexy is present (Criterion B1 not met).
347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin
deficiency: In this rare subtype (less than 5 percent of narcolepsy
cases), Criterion B requirements of cataplexy and positive
polysomnography/multiple sleep latency test are met, but CSF
hypocretin-1 levels are normal (Criterion B2 not met).
347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness,
and narcolepsy: This subtype is caused by exon 21 DNA (cytosine-5)-
methyltransferase-1 mutations and is characterized by late-onset
(age 30 to 40 years) narcolepsy (with low or intermediate CSF
hypocretin-1 levels), deafness, cerebellar ataxia, and eventually
dementia.
347.00 (G47.419) Autosomal dominant narcolepsy, obesity, and type
2 diabetes: Narcolepsy, obesity, and type 2 diabetes with low CSF
hypocretin-1 levels have been described in rare cases and are
associated with a mutation in the myelin oligodendrocyte
glycoprotein gene.
347.10 (G47.429) Narcolepsy secondary to another medical
condition: This subtype is for narcolepsy that develops secondary to
medical conditions that cause infectious (e.g., Whipple's disease,
sarcoidosis), traumatic, or tumoral destruction of hypocretin
neurons.
Coding note (for ICD-9-CM code 347.10 only): Code first the
underlying medical condition (e.g., 040.2 Whipple's disease; 347.10
narcolepsy secondary to Whipple's disease).
Specify current severity:
Mild: Infrequent cataplexy (less than once per week), need for naps
only once or twice per day, and less disturbed nocturnal sleep.
Moderate: Cataplexy once daily or every few days, disturbed
nocturnal sleep, and need for multiple naps daily.
Severe: Drug-resistant cataplexy with multiple attacks daily, nearly
constant sleepiness, and disturbed nocturnal sleep (i.e., movements,
insomnia, and vivid dreaming).
Treatment
§ No cure exists for narcolepsy
§ a regimen of forced naps at a regular time of day occasionally
helps patients with narcolepsy and, in some cases, the
regimen alone, without medication, can almost cure the
condition
§ When medication is required, stimulants are most commonly
used.
§ Modafinil (Provigil), an alpha1-adrenergic receptor agonist,
has been approved to reduce the number of sleep attacks and
to improve psychomotor performance in narcolepsy
§ tricyclic drugs or SSRIs to reduce cataplexy
§ scheduled naps, lifestyle adjustment, psychological
counseling, drug holidays to reduce tolerance, and careful
monitoring of drug refills, general health, and cardiac status
BREATHING-RELATED SLEEP DISORDER
§ characterized by sleep disruption leading to excessive
sleepiness or insomnia caused by a sleep-related breathing
disturbance
§ include apneas, hypopneas, and oxygen desaturations
§ invariably cause hypersomnia.
§ Two disorders of the respiratory system that can produce
hypersomnia : sleep apnea and central alveolar
hypoventilation
TRANSCRIBERS Marky, Josh, Eina
EXIMIUS
2021
OBSTRUCTIVE SLEEP APNEA SYNDROME
§ characterized by periods of functional obstruction of the
upper airway during sleep, resulting in decreases in arterial
oxygen saturation and a transient arousal, after which
respiration (at least briefly) resumes normally.
§ occur in patients who snore
§ patients are overweight, and it appears more frequently in
patients with smaller jaws or true micrognathia, acromegaly,
and hypothyroidism
§ Medical consequences include cardiac arrhythmias, systemic
and pulmonary hypertension, and decreased sexual drive or
function
§ an illness of middle age, primarily in men, but can occur at any
age, including children
§ OSA in adults are characterized by multiple periods of at least
10 seconds in duration in which nasal and oral airflow ceases
completely (an apnea) or partially (a hypopnea
§ Central sleep apnea (CSA), which tends to occur in the elderly,
results from periodic failure of central nervous system (CNS)
mechanisms that stimulate breathing
§ features of CSA are similar to those of OSA, except that, during
the periods of apnea, a cessation of respiratory effort is seen
in the abdominal and chest expansion leads
§ Several features of OSA and CSA:
§ decreased ability to concentrate, decreased libido, memory
complaints, and deficits in neuropsychological testing.
§ Nasal continuous positive airway pressure (nCPAP) is the
treatment of choice for OSA
§ Others: include weight loss, nasal surgery, tracheostomy, and
uvulopalatoplasty
§ SSRIs and heterocyclic antidepressant drugs sometimes help
treat sleep apnea
§ theophylline has been shown to decrease the number of
episodes of apnea
§ avoid the use of sedative medication, including alcohol
CENTRAL ALVEOLAR HYPOVENTILATION
§ refers to several conditions marked by impaired ventilation in
which the respiratory abnormality appears or greatly worsens
only during sleep and in which no significant apneic episodes
are present
§ inadequate tidal volume or respiratory rate during sleep
§ Death may occur during sleep (Ondine's curse).
§ treated with some form of mechanical ventilation (e.g., nasal
ventilation).
CIRCADIAN RHYTHM SLEEP DISORDER
§ includes a wide range of conditions involving a misalignment
between desired and actual sleep periods
§ four types of circadian rhythm sleep disorders: delayed sleep
phase type, jet lag type, shift work type, and unspecified
JET LAG TYPE
§ depending on the length of the east-to-west trip and
individual sensitivity
§ disappears spontaneously in 2 to 7 days
§ no specific treatment is required
§ can prevent the symptoms by altering their mealtimes and
sleep times in an appropriate direction before traveling
§ Melatonin taken orally at prescribed times is useful
§ Maximizing light exposure during the new daytime and
minimizing light during the new nighttime are also helpful
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 PSYCHIATRY III
SLEEP-WAKE DISORDERS
Ethel Maureen Pagaddu, MD December 2019
SHIFT WORK TYPE
§ among night shift workers is to come home in the early
morning, to go to bed feeling exhausted, to sleep only 2 to 3
hours, and to awaken feeling unrefreshed but unable to
continue sleeping
§ strategies, including napping before going into work in the
evening or taking a scheduled nap during nighttime work
hours, may be helpful
§ Using bright light at night and avoiding light during the day
have been proposed
PERIODIC LIMB MOVEMENT SYNDROME
§ also known as nocturnal myoclonus
§ consists of highly stereotyped abrupt contractions of certain
leg muscles during sleep
§ include extension of the toes, as well as flexion of the ankle
and knee
§ patient is usually unaware that these movements occur,
although the bed partner may be only too aware
§ associated with renal disease, as well as iron and vitamin B12
anemia; exacerbated by tricyclic antidepressants
§ of middle age in both sexes, with increasing frequency with
advancing age
§ PLM index of at least five per hour
§ No treatment for nocturnal myoclonus is universally effective
§ may be useful include benzodiazepines, levodopa (Larodopa),
quinine, and, in rare cases, opioids
RESTLESS LEGS SYNDROME
§ also known as Ekbom syndrome
§ an uncomfortable, subjective sensation of the limbs, usually
the legs, described as a “creepy crawly” feeling or as the
sensation of ants walking on the skin
§ worse at night, relieved by walking or moving about
§ a cause of sleep initiation insomnia,: ultimate cause is
unknown but it appears often in pregnancy, iron or vitamin
B12 deficiency anemia, and renal disease
§ first step in treatment is looking for anemia and treating it
§ Benzodiazepines are relatively ineffective
§ off-label use of L-dopa and carbidopa , bromocriptine, and
pergolide is often helpful
§ off-label use of narcotic analgesics can help when other
treatments have been tried and have failed
§ Ropinirole (Requip), a dopamine agonist available for
treatment of Parkinson's disease, now the first drug approved
by the FDA for treatment of moderate to severe RLS
KLEINE-LEVIN SYNDROME
§ a relatively rare condition consisting of recurrent periods of
prolonged sleep (from which patients may be aroused) with
intervening periods of normal sleep and alert waking
§ During the hypersomniac episodes, wakeful periods are
usually marked by withdrawal from social contacts and return
to bed at the first opportunity; patients may also display
apathy, irritability, confusion, voracious eating, loss of sexual
inhibitions, delusions, hallucinations, frank disorientation,
memory impairment, incoherent speech, excitation or
depression, and truculence.
§ Uncommon
§ first attack occurs between the ages of 10 and 21 years
§ invariably self-limited, and enduring remission occurs
spontaneously before age 40 in early-onset cases
TRANSCRIBERS Marky, Josh, Eina
EXIMIUS
2021
PARASOMNIAS
NIGHTMARE DISORDER
§ Nightmares are vivid dreams that become progressively more
anxiety producing, ultimately resulting in an awakening
§ nightmares almost always occur during REM sleep and usually
after a long REM period late in the night
§ No specific treatment is usually required for nightmare
disorder.
§ Agents that suppress REM sleep, such as tricyclic drugs, may
reduce the frequency of nightmares,
§ benzodiazepines have also been used
SLEEP TERROR DISORDER
§ an arousal in the first third of the night during deep NREM
(stages III and IV) sleep
§ inaugurated by a piercing scream or cry and accompanied by
behavioral manifestations of intense anxiety bordering on
panic
§ Patients may remain awake in a disoriented state, but more
often fall asleep, and as with sleepwalking, they forget the
episodes
§ A night terror episode after the original scream frequently
develops into a sleepwalking episode
§ About 1-6% of children have the disorder; more common in
boys than in girls; tends to run in families
§ Specific treatment is seldom required
§ individual or family therapy is sometimes useful
§ diazepam (Valium) in small doses at bedtime improves the
condition
SLEEPWALKING DISORDER
§ known as somnambulism
§ consists of a sequence of complex behaviors that are initiated
in the first third of the night during deep NREM (stage III and
IV) sleep and frequently, although not always, “progress
without full consciousness or later memory of the episode” to
leaving bed and walking about
§ The behavior occasionally terminates in awakening, with
several minutes of confusion; more frequently, the person
returns to sleep without any recollection of the sleepwalking
event
§ begins between ages 4 and 8 and tends to dissipate in
adolescence; peak prevalence is at about 12 years old
§ more common in boys
§ tends to run in families
§ a minor neurological abnormality probably underlies the
condition; should not be considered purely psychogenic
§ Treatment: primarily of educating and reassuring the parents
§ Medical intervention is rarely needed for typical night terrors
or sleepwalking
§ in difficult cases, off-label use of benzodiazepines, which
decrease slow-wave sleep
REM SLEEP BEHAVIOR DISORDER
§ episodes of complex, often violent, behavior and is thought to
represent a patient acting out his or her dreams
§ more common in older men
§ often a history exists of a small stroke or other CNS insult in
the last months or year.
§ can also appear as an early event in the evolution of
Parkinson's disease
§ most widely used treatment is the off-label administration of
clonazepam , 0.5 to 2.0 mg a day
§ Carbamazepine, 100 mg three times a day, is also effective
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 PSYCHIATRY III EXIMIUS
SLEEP-WAKE DISORDERS
2021
Ethel Maureen Pagaddu, MD December 2019

SLEEPTALKING (SOMNILOQUY)
§ in children and adults
§ found in all stages of sleep
§ involves a few words that are difficult to distinguish
§ involve the sleeper's life and concerns, but sleeptalkers do not
relate their dreams during sleep, nor do they often reveal
deep secrets
§ sometimes accompany night terrors and sleepwalking
§ requires no treatment

SLEEP-RELATED HEAD BANGING (JACTATIO CAPITIS NOCTURNA)

§ a sleep behavior consisting chiefly of rhythmic to-and-fro head
rocking (less commonly, total body rocking) occurring just
before or during sleep
§ observed in the immediate presleep period and is sustained
into light sleep
§ uncommonly persists into, or occurs in, deep NREM sleep
§ Treatment consists of measures to prevent injury

SLEEP PARALYSIS
§ Familial sleep paralysis is characterized by a sudden inability
to execute voluntary movements, either just at the onset of
sleep or on awakening during the night or in the morning

TRANSCRIBERS Marky, Josh, Eina 5